What is the recommended treatment for ankle roll injuries?

Recommended Treatment for Ankle Roll Injuries

Start exercise therapy immediately with functional bracing—RICE alone is ineffective and should not be used as the primary treatment modality. 1

Initial Assessment

• Apply the Ottawa Ankle Rules to determine if radiography is needed to rule out fractures, which reduces unnecessary x-rays by approximately 60% 2
• Delay definitive physical examination for 4-5 days post-injury when swelling has decreased, as the anterior drawer test achieves optimal sensitivity (84%) and specificity (96%) at this timepoint 1, 3
• Avoid stress radiographs and arthrography as they are obsolete and provide no additional diagnostic value 1

Acute Phase Management (First 3-5 Days)

What NOT to Do

• Do not use RICE (Rest, Ice, Compression, Elevation) alone as your treatment strategy—there is no evidence that RICE alone has any positive influence on pain, swelling, or patient function 1
• Avoid immobilization entirely—it shows no benefits compared to functional treatment and delays recovery 1, 3, 2
• Do not apply ice alone, as isolated cryotherapy does not increase function or decrease swelling and pain at rest 1

What TO Do

• Initiate NSAIDs (such as piroxicam, celecoxib, or naproxen) to reduce pain and swelling, which accelerates return to activity 1, 4
• Apply a semirigid ankle brace immediately—this is the most cost-effective option and superior to taping or elastic bandages 4, 2
• If using cryotherapy, combine it with exercise therapy (not alone), as this combination reduces swelling more effectively than heat and improves short-term ankle function 1, 5
• Apply cold for 20-30 minutes per application without direct skin contact to avoid cold injury 3, 4
• Compression wraps may be used for comfort but ensure circulation is not compromised 4

Exercise Therapy Protocol (Begin Within 48-72 Hours)

This is the treatment with the strongest evidence (Level 1) and should start as soon as possible. 1, 3, 4, 2

Supervised Exercise Components

• Proprioception training to restore joint position sense 3, 4, 5, 2
• Strengthening exercises addressing muscle deficits and response time 4, 2
• Coordination exercises 3, 4, 5
• Range of motion exercises to prevent stiffness 4, 2
• Sport-specific functional exercises as recovery progresses 3, 4, 2

Supervised exercises provide better outcomes than non-supervised training, so refer to physical therapy when possible 2

Functional Support Strategy

• Braces are strongly preferred over tape or elastic bandages for both treatment and prevention 1, 3, 4
• Lace-up or semirigid ankle supports are more effective than elastic bandages 4
• Continue bracing during return to activity, as it is superior to taping and neuromuscular training for preventing recurrent sprains (Level 1 evidence) 2
• Avoid Tubigrip elastic tubular bandages—they have no positive effect on functional recovery and may increase analgesic requirements 6

Return to Activity Timeline

• Functional treatment allows return to sports approximately 4.6 days sooner than immobilization 4, 5, 2
• Patients return to work 7.1 days sooner with functional treatment compared to immobilization 4, 2
• Immediate functional treatment with a return-to-work schedule minimizes work absenteeism 1, 2

Special Considerations

Manual Mobilization

• Only use manual mobilization in combination with other treatment modalities to enhance treatment effect—never as standalone therapy 1, 3, 5

Surgery

• Reserve surgery only for professional athletes requiring rapid recovery or patients with persistent symptoms after failed conservative treatment 1, 3
• The vast majority of ankle sprains heal with conservative functional treatment 2, 7

High Ankle Sprains (Syndesmotic Injuries)

• Suspect when the crossed-leg test (pressure on medial knee) produces pain in the syndesmosis area 4, 5
• These require more intensive rehabilitation and longer recovery time 4
• Consider MRI if high-grade ligament injuries, osteochondral defects, or syndesmotic injuries are suspected, as MRI has excellent sensitivity (93-96%) and specificity (100%) 1

Critical Pitfalls to Avoid

• Excessive imaging without applying Ottawa Ankle Rules 2
• Unwarranted non-weight-bearing—early weight-bearing is essential 2
• Unjustified immobilization—this is the most common error and significantly delays recovery 1, 2
• Delay in functional movements—start exercise within 48-72 hours 4, 2
• Inadequate rehabilitation—this leads to chronic pain, decreased range of motion, and joint instability affecting 16-40% of patients 4, 2, 8

Prevention of Recurrent Sprains

• Continue wearing a semirigid ankle brace during sports activities 2
• Incorporate exercise therapy into regular training activities for patients with recurrent sprains 1, 3, 5
• Implement neuromuscular training programs including proprioceptive exercises 2